Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Endovascular Intervention for Life-threatening Hemoptysis

Video 1. Pre-embolization video showing collateral vessels.

 

Video 2. Post embolization video showing the endovascular implants and cessation of collateral flow.

 

Idiopathic pulmonary arterial hypertension (PAH) is an uncommon life threatening disease characterized by a progressive increase in pulmonary vascular resistance with subsequent right ventricular failure and death. Hemoptysis is known to be one of the complications in PAH patients although the exact incidence and mechanism of hemoptysis remains unclear (1,2).

Ours is a case of a 40-year-old woman with known severe idiopathic pulmonary hypertension who was admitted for recurrent episodes of hemoptysis for the past one month. On her first presentation with non-massive hemoptysis, she underwent elective embolization with Amplatzer® vascular plug (St. Jude Medical, St. Paul, MN USA) of the aorto-pulmonary collaterals. These included a large collateral off the right subclavian artery, right internal mammary artery and a large collateral off the descending aorta to the right lung (Video 1). Her hemoptysis resolved. She was admitted seven days’ post first embolization with massive hemoptysis, and immediately underwent repeat embolization with Onyx® (Medtronic, Minneapolis, MN USA), a non-adhesive liquid embolic agent. Embolization was performed on the right intercostal arteries, left bronchial artery, with some abnormal vessels noticed (Video 2).  No active bleeding was visualized during the procedure. Hemoptysis resolved once again.

The management of hemoptysis in patients with PAH remains indeterminate. However, embolization of bronchial arteries has been recommended as an effective method of managing PAH patients with recurrent hemoptysis to control the acute hemorrhage (2,3).

See-Wei Low MBBS1 Huthayfa Ateeli, MBBS2

1Department of Medicine and 2Division of Pulmonary, Allergy, Critical Care, and Sleep

Banner University Medical Center

Tucson, AZ, USA

References

  1. Broberg C, Ujita M, Babu-Narayan S, Rubens M, Prasad SK, Gibbs JS, Gatzoulis MA. Massive pulmonary artery thrombosis with hemoptysis in adults with Eisenmenger's syndrome: a clinical dilemma. Heart. 2004;90:e63. [CrossRef] [PubMed]
  2. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121:789-95. [CrossRef] [PubMed]
  3. Reesink HJ, van Delden OM, Kloek JJ, Jansen HM, Reekers JA, Bresser P. Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature. Cardiovasc Intervent Radiol. 2007;30:136-9. [CrossRef] [PubMed] 

Cite as: Low S-W, Ateeli H. Medical image of the week: endovascular intervention for life-threatening hemoptysis. Southwest J Pulm Crit Care. 2017;14(2):86-7. doi: https://doi.org/10.13175/swjpcc017-17 PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Bronchial Artery Embolization

Figure 1. Thoracic CT with contrast demonstrating right upper and lower lobe tree-in-bud and ground glass opacities (arrows) consistent with progressing pulmonary coccidioidomycosis.

 

Figure 2. Chest radiograph demonstrates the ethylene vinyl alcohol polymer retained in the bronchial arteries after the embolization procedure (arrows).

 

A 25-year-old woman with a past medical history significant for pulmonary coccidioidomycosis and poorly controlled type I diabetes mellitus presented to the emergency department with a chief complaint of 4 days of progressively worsening shortness of breath and 3-4 days of intermittent hemoptysis. Initial CT scan demonstrated progressive tree-in-bud and ground glass opacities in the right upper and lower lung lobes suggesting worsening of her ongoing coccidiomycosis (Figure 1). On hospital day 3 she began to have worsening hypoxemia and hemoptysis requiring transfer to the intensive care unit. Interventional radiology was consulted who performed an emergent right sided bronchial artery embolization with the ethylene vinyl alcohol polymer, Onyxtm. After embolization her chest radiographs demonstrated evidence of the embolization material in the pulmonary vasculature (Figure 2).

Ethylene vinyl alcohol polymer, Onyxtm is a liquid embolic substance which solidifies after contact with ionic materials (1). This results in a rapid, irreversible and permanent embolization of the bleeding target vessel (2). It was initially approved for use in the embolization of cerebral arteriovenous malformations, however has been used for rapid embolization of other hemorrhagic conditions such has hemoptysis from bleeding bronchial arteries (3). The most common complication after embolization is chest pain that is self-limiting. Transverse myelitis from spinal cord ischemia is the most serious complication associated with bronchial artery embolization however the occurrence is significantly decreased by spinal arterial identification during initial angiography (4). This patient’s embolization was without complications. She was successfully extubated on hospital day 15 without evidence of ongoing hemoptysis and will continue to follow up in the pulmonary and infectious disease clinics for ongoing treatment of her Coccidiodes pulmonary disease.

Benjamin J. Jarrett MD, MPH and Sachin Chaudhary, MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

  1. Lubarsky M, Ray C, Funaki B. Embolization agents-which one should be used when? Part 2: small-vessel embolization. Semin Intervent Radiol. 2010 Mar;27(1):99-104. [CrossRef] [PubMed]
  2. Yamashita K, Taki W, Iwata H, Nakahara I, Nishi S, Sadato A, Matsumoto K, Kikuchi H. Characteristics of ethylene vinyl alcohol copolymer (EVAL) mixtures. AJNR Am J Neuroradiol. 1994 Jun;15(6):1103-5. [PubMed]
  3. Guimaraes M, Wooster M. Onyx (Ethylene-vinyl Alcohol Copolymer) in Peripheral Applications. Semin Intervent Radiol. 2011 Sep;28(3):350-6. [CrossRef] [PubMed]
  4. Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2011 Mar;28(1):48-62. [CrossRef] [PubMed]

Cite as: Jarrett BJ, Chaudhary S. Medical image of the week: bronchial artery embolization. Southwest J Pulm Crit Care. 2016;13(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc053-16 PDF

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